Should we wait for a patient with intermediate-high-risk pulmonary embolism to deteriorate before pursuing reperfusion—or intervene before the right ventricle fails?

In this episode of PRISM Rounds, we examine PRAGUE-26, a multicenter randomized trial published in the New England Journal of Medicine comparing conventional catheter-directed thrombolysis with low-dose alteplase plus anticoagulation against anticoagulation alone in patients with intermediate-high-risk acute pulmonary embolism.

The headline result is striking: the 7-day composite of death, recurrent pulmonary embolism, or cardiorespiratory decompensation or collapse occurred in 0.7% with catheter-directed thrombolysis versus 6.8% with standard care. But the interpretation requires nuance. The benefit was driven primarily by fewer episodes of cardiorespiratory deterioration, not a demonstrated mortality reduction. Overall major bleeding was not clearly increased, yet two intracranial hemorrhages occurred in the thrombolysis group and none with anticoagulation alone.

We break down patient selection, the low-dose alteplase strategy, the composite endpoint, rescue reperfusion, early RV recovery, bleeding risk, and the limitations of an open-label trial conducted in experienced tertiary cardiovascular centers. Most importantly, we ask what prague-26 should change at the bedside: Does this trial support routine early catheter-directed thrombolysis, or does it help us identify the selected patient who should undergo reperfusion before overt hemodynamic collapse?

The article was published online in the New England Journal of Medicine on August 31, 2026, DOI 10.1056/NEJMoa2608012.

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Journal article:
Read “Catheter-Directed Thrombolysis in Intermediate-High-Risk Pulmonary Embolism” in NEJM

Tags:
#PRISMRounds #PRISMTrials #CriticalCare #CriticalCareMedicine #ICU #PulmonaryCriticalCare #PulmonaryMedicine #Pulmonology #PulmonaryEmbolism #PE #IntermediateHighRiskPE #SubmassivePE #CatheterDirectedThrombolysis #CDT #Thrombolysis #Alteplase #Anticoagulation #Reperfusion #PERT #PulmonaryEmbolismResponseTeam #RightVentricle #RVFailure #RightHeartStrain #HemodynamicCollapse #CardiorespiratoryDecompensation #Shock #VTE #VenousThromboembolism #EmergencyMedicine #Cardiology #InterventionalCardiology #IntensiveCare #ClinicalTrials #RandomizedTrial #RCT #EvidenceBasedMedicine #MedicalEducation #JournalClub #NEJM #FOAMed #FOAMcc #MedEd #EvidenceBasedCriticalCare

In this episode of PRISM Rounds, we discuss the SAVE-O2 AI randomized clinical trial, which tested autonomous closed-loop oxygen titration versus usual manual oxygen adjustment in 300 hospitalized adults receiving supplemental oxygen.

The autonomous system kept patients in the target SpO2 range much more often, 85% vs 63%, while also reducing time spent in hypoxemia and, even more strikingly, hyperoxemia. We break down what the trial shows, what it does not show, the importance of pulse oximetry accuracy and skin pigmentation, and whether improved oxygen control is enough to justify broader implementation.

We also discuss the accompanying editorial by Weingart and Matthay, which explores the potential impact on clinician workload, oxygen stewardship, resource-limited settings, and the next generation of implementation and outcomes studies.

SAVE-O2 AI trial, JAMA Internal Medicine
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2026.4023
DOI: https://doi.org/10.1001/jamainternmed.2026.4023

Invited Commentary: Potential Transformative Impact of Autonomous Oxygen Delivery in Hospitalized Patients
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2026.4038
DOI: https://doi.org/10.1001/jamainternmed.2026.4038

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Tags
#PRISMRounds #SAVE02AI #CriticalCare #ICU #PulmonaryCriticalCare #OxygenTherapy #Hypoxemia #Hyperoxemia #PulseOximetry #ClosedLoopControl #ArtificialIntelligence #DigitalHealth #ClinicalTrials #RandomizedTrial #JAMAInternalMedicine #RespiratoryCare #FOAMcc #MedEd

Does video laryngoscopy improve first pass success for routine tracheal intubation, and does blade geometry matter?

In this episode of PRISM Rounds, we discuss the COVALENT randomized clinical trial, which compared direct laryngoscopy, Macintosh style video laryngoscopy, and hyperangulated video laryngoscopy in more than 2,400 perioperative intubations.

We review the higher first pass success with video laryngoscopy, why the hyperangulated strategy performed best, the important role of stylet use, and what the accompanying editorial adds to the interpretation.

We also discuss how COVALENT builds on the DEVICE trial in critically ill adults and why the airway conversation may now be shifting from simply video versus direct toward which video strategy, blade, and adjunct work best in different clinical settings.

Find PRISM Rounds on Apple Podcasts, Spotify, and https://prismrounds.com

Tags:
Critical Care, ICU, Airway Management, Video Laryngoscopy, Direct Laryngoscopy, COVALENT Trial, DEVICE Trial, Tracheal Intubation, First Pass Success, Emergency Airway, Anesthesiology, Pulmonary Critical Care, Evidence Based Medicine, Journal Club, PRISM Rounds, FOAMcc, FOAMed

Description
We obsess over the paralytic, but are we giving enough of it?

In this episode of PRISM Rounds, we review a new AJRCCM secondary analysis of 1,822 critically ill adults from the DEVICE and PREOXI trials examining whether rocuronium dose is associated with first-attempt intubation success.

Patients receiving more than 1.2 mg/kg had higher first-attempt success overall, with the strongest signal in ICU patients. But rocuronium dose was chosen by clinicians rather than randomized, so residual confounding matters.

We break down the study, the accompanying editorial, the pharmacologic rationale for higher dosing, the ICU versus ED findings, and the key bedside question: Should this change how we dose rocuronium during emergency intubation?

Original article:
https://academic.oup.com/ajrccm/article/212/8/1740/8679093

Accompanying editorial:
https://academic.oup.com/ajrccm/article/212/8/1680/8706698

Educational use only. This is not medical advice.

Tags
Critical Care, ICU, Airway Management, Tracheal Intubation, Emergency Intubation, Rocuronium, Neuromuscular Blockade, Rapid Sequence Intubation, RSI, First Pass Success, First Attempt Success, Video Laryngoscopy, DEVICE Trial, PREOXI Trial, AJRCCM, Pulmonary Critical Care, Emergency Medicine, Anesthesiology, Evidence Based Medicine, Journal Club, Medical Education, PRISM Rounds

Can early in-bed cycling plus intravenous amino acids improve recovery after critical illness?

The NEXIS trial randomized 115 adults with acute respiratory failure to protocolized cycling plus higher amino acid delivery or usual care. The intervention substantially increased rehabilitation time and protein intake, but did not improve six-minute walk distance at hospital discharge, strength, duration of ventilation, length of stay, mortality, or six-month recovery.

This episode examines the trial design, intervention delivery, safety findings, limitations, and bedside implications. The discussion also addresses why a biologically plausible intervention may fail to produce better patient-centered outcomes, and why the results should not be interpreted as an argument against individualized ICU rehabilitation.

Tags

PRISM Rounds, NEXIS trial, critical care, intensive care, ICU rehabilitation, ICU acquired weakness, early mobility, in-bed cycling, cycle ergometry, amino acids, protein supplementation, acute respiratory failure, mechanical ventilation, six-minute walk distance, physical function, critical illness recovery, post-intensive care syndrome, nutrition in critical illness, AJRCCM, randomized clinical trial, pulmonary critical care, evidence-based medicine, journal club, medical education

Should mechanically ventilated patients with difficult-to-clear secretions routinely receive carbocisteine or nebulized hypertonic saline?

In this episode of PRISM Rounds, we examine the MARCH randomized trial, which enrolled 1,956 patients across 71 UK intensive care units. Neither intervention shortened mechanical ventilation or improved major clinical outcomes. However, carbocisteine increased clinically important gastrointestinal bleeding, while hypertonic saline increased bronchoconstriction and hypoxemia during nebulization.

We discuss the trial’s factorial design, the absence of a number needed to treat, and the approximate numbers needed to harm: 88 for gastrointestinal bleeding with carbocisteine, 51 for bronchoconstriction with hypertonic saline, and 26 for hypoxemia during nebulization. We then translate these findings into practical de-implementation strategies for airway care in the ICU.

Article:
https://www.nejm.org/doi/10.1056/NEJMoa2603406

Educational use only. This podcast is not medical advice.

Tags
MARCH trial, carbocisteine, hypertonic saline, mucoactive agents, mechanical ventilation, acute respiratory failure, airway secretions, mucus clearance, hypoxemia, bronchoconstriction, gastrointestinal bleeding, critical care, intensive care, ICU, respiratory therapy, pulmonary medicine, evidence-based medicine, randomized clinical trial, de-implementation, NEJM, PRISM Rounds

In this episode of PRISM Rounds, we review the VICTORY randomized clinical trial, published in JAMA on June 10, 2026, testing high-dose intravenous vitamin C in patients with severe burn injury.

The trial randomized adults with deep second- or third-degree burns involving at least 20% total body surface area to high-dose IV vitamin C or placebo. VICTORY was stopped early for futility and harm. Vitamin C did not improve death or persistent organ dysfunction and raised concerning mortality signals.

We discuss how the trial was conducted, why vitamin C was biologically appealing, what the results showed, and what this means for medical ICU patients with shock, sepsis, ARDS, and inflammatory critical illness.

Article: https://doi.org/10.1001/jama.2026.10616

Educational content only; not medical advice.

Critical Care, ICU, Medical ICU, Burn ICU, Severe Burns, Vitamin C, High-Dose Vitamin C, Ascorbic Acid, VICTORY Trial, JAMA, Randomized Clinical Trial, Organ Dysfunction, Shock, Sepsis, ARDS, Mortality, Evidence Based Medicine, Pulmonary Critical Care, Emergency Medicine, Pharmacy, Nursing, Respiratory Therapy, PRISM Rounds

Tags

In this episode of PRISM Rounds, we discuss the JAMA randomized clinical trial BIHCA, which tested whether routine sodium bicarbonate improves outcomes during adult in-hospital cardiac arrest.

Granfeldt and colleagues randomized adults with in-hospital cardiac arrest who had received epinephrine to sodium bicarbonate or placebo. Sustained return of spontaneous circulation occurred in 39% with bicarbonate vs 37% with placebo, with no significant difference. Survival and favorable neurologic outcome were also not clearly improved, while alkalosis and hypernatremia were more common with bicarbonate.

We also discuss the accompanying editorial by Clifton Callaway, which asks whether this high-quality trial will change practice, given how deeply bicarbonate remains embedded in code culture despite guideline recommendations against routine use.

Bottom line: bicarbonate changed the blood gas, but it did not change the patient-centered trajectory. Routine sodium bicarbonate should not be reflexive during in-hospital cardiac arrest, but targeted use remains appropriate for specific indications such as hyperkalemia or toxicologic sodium-channel blockade.

Source article: https://doi.org/10.1001/jama.2026.10628
Editorial: https://doi.org/10.1001/jama.2026.10508

Tags

critical care, ICU, cardiac arrest, in-hospital cardiac arrest, sodium bicarbonate, bicarbonate, BIHCA, resuscitation, ACLS, code blue, epinephrine, return of spontaneous circulation, ROSC, neurologic outcome, JAMA, clinical trials, randomized trial, evidence-based medicine, emergency medicine, hospital medicine, pulmonary critical care, PRISM Rounds, FOAMed, medical education, CriticalCare, ICU, CardiacArrest, Resuscitation,